The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
J Bone Joint Surg Am. 2013 Aug 21;95(16):e115(1-6). doi: 10.2106/JBJS.L.00847.
Some children have persistent pain and instability following inversion injuries of the ankle. Radiographs may reveal a small osseous fragment distal to the lateral malleolus, suggesting an avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. The avulsion injury may involve an os subfibulare, causing ligamentous laxity and chronic pain resulting from nonunion. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. The purpose of this study was to evaluate the intraoperative findings and long-term outcomes of patients treated operatively for symptomatic avulsion injuries or a symptomatic os subfibulare.
Twenty-three patients presented with chronic ankle pain and instability, tenderness anterior and distal to the lateral malleolus, and imaging studies (magnetic resonance imaging and/or stress radiographs) suspicious for avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. After unsuccessful nonoperative treatment, all patients underwent excision of the osseous fragments, anatomic reconstruction of the anterior talofibular ligament with use of drill holes through the lateral malleolus, and a modified Broström procedure.
The mean age of the patients was 10.4 years (range, eight to thirteen years) at the time of injury and 13.6 years (range, eight to seventeen years) at the time of surgery, representing a mean delay in diagnosis and treatment of 3.2 years. At a mean follow-up of 4.5 years (range, 2.1 to 13.2 years), the mean Foot and Ankle Outcome Score was 91.4 (range, 87 to 98) out of 100, with all but one patient returning to the preinjury recreational level. Only one patient had a long-term complication.
In children with chronic pain and instability associated with an os subfibulare, surgical excision of the os subfibulare combined with reconstruction of the anterior talofibular ligament and a modified Broström procedure was effective in restoring ankle stability, eliminating pain, and permitting return to the preinjury functional level.
一些儿童在踝关节扭伤后会持续出现疼痛和不稳定。X 线片可能会显示外踝远端的小骨碎片，提示前距腓韧带和/或跟腓韧带的撕脱伤。撕脱伤可能涉及距腓骨下骨，导致韧带松弛和因不愈合而引起的慢性疼痛。这种情况必须与无症状的距腓骨下骨区分开来，在 1%的儿童中，这是一种正常的解剖变异。本研究的目的是评估手术治疗有症状的撕脱伤或有症状的距腓骨下骨的患者的术中发现和长期结果。
23 例患者因慢性踝关节疼痛和不稳定、外踝前下方压痛就诊，影像学检查（磁共振成像和/或应力 X 线片）提示前距腓韧带和/或跟腓韧带撕脱伤。在非手术治疗失败后，所有患者均行骨碎片切除术，通过外踝钻孔进行前距腓韧带解剖重建，并采用改良的 Broström 手术。
患者的平均年龄为受伤时 10.4 岁（8-13 岁），手术时 13.6 岁（8-17 岁），平均诊断和治疗延迟 3.2 年。平均随访 4.5 年（2.1-13.2 年）时，足踝评分平均为 91.4（87-98）分，除 1 例患者外，其余患者均恢复到受伤前的娱乐水平。仅 1 例患者出现长期并发症。
对于伴有距腓骨下骨的慢性疼痛和不稳定的儿童，距腓骨下骨切除术结合前距腓韧带重建和改良的 Broström 手术可有效恢复踝关节稳定性，消除疼痛，并恢复到受伤前的功能水平。
